Sobrevida de la disfunción sistólica severa del ventrículo izquierdo con la terapia farmacológica actual / Survival of patients with severe left ventricular systolic dysfunction under current medication

Antecedentes: La disfunción sistólica severa del ventrículo izquierdo, con su secuela de insuficiencia cardiaca(IC) ha aumentado en las dos últimas décadas, pero su mortalidad ha disminuido con la introducción delos inhibidores de la enzima convertidora y beta-bloqueadores de tercera generación. Objetivo: Evaluar la sobrevida de un grupo de pacientes con IC desde su primera crisis Métodos: Seguimiento de una cohorte de 24 pacientes con IC de diversas etiologías (hipertensiva, alcohólica e idiopática), pero con predominio de arterioesclerosis coronaria (16 pac) durante 11 años. Los pacientes fueron tratados con terapia asociada de enalapril y carvedilol en dosis bajas, además del tratamiento clásico de la IC. Resultados: La mortalidad global fue de 8 pac (33 por ciento) y, expresada en años de seguimiento, fue de 1.8 pac/año. Las crisis de descompensación alcanzaron el 54 por ciento y las hospitalizaciones el 46 por ciento. Conclusiones: En nuestra experiencia, el tratamiento con inhibidores de la enzima convertidora y beta-bloqueadores de tercera generación, asociados a la terapia clásica de la IC, permitió una sobrevida satisfactoria a largo plazo.

Background: Severe left ventricular systolic dysfunction leading to congestive heart failure (CHF) has become more prevalent in the last decades, but mortality from this condition has decreased following the introduction of convertingenzymeinhibitors (ACE) and third generation beta blockers. Aim: To evaluate survival in a group of patients with CHF Methods: Twenty-four patients with congestive heart failure secondary to coronary artery disease (n=16), hypertension, alcoholic or idiopathic cardiomyopathy were followed during 11 years. Patients were treated with combined therapy of enalapril and low dose carvedilol, along with other conventional drugs. Results: Eight patients died during follow up (33 percent or 1.8 patients per year). Decompensation of heart failure occurred in 54 percent and rehospitalization in 46 percent of patients. Conclusion: Treatment with an ACE inhibitor and a third generation beta blocker along with conventional drugs was associated to a satisfactory long term survival in patients with CHF.

Test de estimulación intraarterial selectiva con calcio en el diagnóstico de localización de insulinomas: Casos clínicos / Selective intra arterial calcium stimulation for the localization of insulinomas: Report of two cases

Insulinoma is the most common neuroendocrine tumor. Its clinical manifestations are frequently confounded with neuropsychiatric symptoms, and definitive diagnosis can be delayed for a long time. These tumors are usually small, of less than 2 cm. Thus, their preoperative localization is difficult. We report two patients with a clinical diagnosis of insulinoma, in whom the preoperative imaging study was negative. Both fulfilled diagnostic criteria, with high serum insulin levels in the presence of a blood glucose of less than 45 mg/dl. The imaging study, including abdominal computed tomography and pancreatic endoscopic ultrasonography did not disclose the location of the tumor. A pancreatic angiography with selective stimulation with intra arterial calcium and venous sampling for insulin measurements, was performed in both patients. This test allowed the exact localization of the tumors and their successful excision. A review of other localization diagnostic tests is done (Rev Méd Chile 2004; 132: 71-5).

Hemorragia digestiva oculta por un tumor del intestino delgado / Occult digestive hemorrhage due to a tumor of the small intestine

La hemorragia digestiva de origen oculto se define por la incapacidad de precisar el sitio de sangrado después de una endoscopia alta y una colonoscopia. Corresponde al 5 por ciento de las hemorragias gastrointestinales. En estos pacientes la cintigrafía con glóbulos rojos marcados, la arteriografía y la enteroscopia intraoperatoria pueden contribuir al diagnóstico y a localizar el sitio de hemorragia. Se presenta un caso clínico de hemorragia digestiva baja de origen oculto. Corresponde a un varon de 56 años sin antecedentes mórbidos, que desde enero del 2000 presenta nueve episodios de sangrado digestivo con múltiples hospitalizaciones y transfusiones repetidas por anemia. En todas éstas se realizó una endoscopia alta y en tres oportunidades una colonoscopia, todas ellas normales. Además, se realizó un tránsito baritado de intestino delgado y una tomografía computada de abdomen también normales. Durante la última hospitalización se solicitó una cintigrafía con globulos rojos marcados que mostró una extravasación del radiofármaco en la fosa ilíaca derecha en relación al intestino delgado. Se realizó una laparotomia exploradora encontrándose un tumor de intestino delgado a 60 centímetros de la válvula íleo cecal practicándose una resección en cuña, con lo que se observa una ulceración de la mucosa con un sangrado activo. Evolucionó en buenas condiciones, sin sangrado, y mantiene controles en policlínico. La biopsia mostró un tumor estromal gastrointestinal benigno.

Insulinemia en ayunas como marcador simple de resistencia a la insulina en hipertensos / Fasting insulinemia as simple marker of insulin resistance in hypertensive patients

Insulin resistance is associated to hypertension, obesity and diabetes and may be an independent cardiovascular risk factor. The exact assessment of insulin resistance requires complex metabolic studies. However, there is a good correlation between this parameter and fasting serum insulin levels. The aim of this work was to study fasting serum insulin levels by ratio immuno analysis in 43 hypertensive patients aged 56 ñ 5.5 years old (27 male, 17 obese and 8 diabetics) and 20 normotensive controls aged 50 ñ 4.8 years old (13 male). Insulin levels were 3.8 UI/L in controls, 12.1 UI/L in normal weight, 15.5 UI/L in obese and 18.3 UI/L in diabetic hypertensives (ANOVA p<0.001). These levels were above two standard deviation of control values in 50 percent of normal weigth, 66 percent of obese and 62 percent diabetic hypertensives. It is conclude that normal weigth, obese and diabetic hypertensive subjects have high fasting insulin levels

Celiprolol en el tratamiento de la angina crónica estable / Treatment of chronic stable angina with celiprolol

Celiprolol is a third generation beta blocking drug with intrinsic vasodilator effect. We evaluated the effect of this drug at a fixed dose of 400 mg daily in 20 patients with coronary artery disease and stable angina having 2 to 40 episodes of pain a week. All patients had positive exercice stress test with > 1 mm ST depression. Compared to the 1 month baseline placebo phase, patients after 3 months of tratment with celiprolol had less episodes of angina (2.4 vs 7.2 a week, p < 0.001), higher angina threshol (667 vs337 sec, p < 0.025), higher ischemia threshold (614 vs 401 sec, p < 0.001) and were able to perform mor work (3937 vs 2403 Kgm/min.p < 0.01). 9 patients had no pain during exercise. A decrease in blood pressure, heart rate and double product was evident in the stress tests of the active phase. adverse effects included headache (4 patients), sweating (1) and fatigue (1) not requiring modification of drug dose. No adverse effects were seen in 13 patients. Thus, celiprolol is effective to decrease angina during daily life and increase excercise tolerance in patients with chronic stable angina pectoris